[Xeesal: Cosmetic skin whitening in subsaharan Africa].

The use of skin lightening products is a widespread practice in sub-Saharan Africa. We observed this practice during a cooperative project conducted in Senegal. In this letter we do not provide an in-depth study or a detailed analysis, rather we give an outline of this practice, illustrating it with anecdotal cases that required attention due to the adverse effects caused by the skin lightening products. In Senegal this practice is called Xeesal1 (“lighten” in the Wolof language). These products are also used in Asian countries.2 This custom is condemned by official bodies in many African countries, and has even been prohibited in some of them, leading to attempts to conceal the practice.1,2 Despite this, some studies have reported that half of the patients visiting a dermatologist for any reason in these countries admit to using Xeesal. The users tended to be married, monogamous women with a relatively high cultural level according to some articles (assessed by their ability to speak French)2 or either lacking education or having a primary education (69%); according to others,1 they were mainly middle class, and engaged in this practice to lighten their skin for cosmetic reasons and to achieve greater social status.2 These products can be acquired at a low cost in most of the larger markets and consist mainly of high potency corticosteroids, hydroquinone, mercury-based compounds and caustic agents, usually in combination.1-3 They are applied to the whole body for years, once or twice a day, and rather than stopping the practice during pregnancy and lactation, their use increases due to the mother’s anxiety to appear radiant at the time of baptism.3,4 The most commonly used corticosteroid is clobetasol,4 which belongs to the highest potency group. Its use causes atrophy, dyschromia, hypertrichosis, and striae (Figure 1), as well as acne that can be inflammatory and resistant to treatment. It also increases susceptibility to skin infections with atypical features: disseminated dermatophytoses (Figure 2), which are inflammatory and resistant to conventional treatment; necrotizing cellulitis; extensive scabies with crusted lesions; and tinea versicolor is also more common. The mode of use described above increases the likelihood of systemic absorption, which can lead to hypertension and diabetes5, especially if use is continued for more than 10 years, and to Cushing syndrome or adrenal insufficiency when discontinued.4 The use of corticosteroids reduces the irritation caused by other compounds that are added to the product, such as hydroquinone. This is a benzene derivative that blocks melanin synthesis. It is used at concentrations higher than 5% and could act as a carcinogen.4 Both properties would theoretically increase the risk of skin cancer in a race in which this is rare, although no case has yet been reported. The practice can cause irritant or allergic contact dermatitis, telangiectasias, atrophy, acne, neuropathy, anaphylactic reactions and, due to their photosensitizing effect, may be associated with rashes similar to lupus erythematosus.3,6 In addition, it causes exogenous ochronosis (Figure 3) in which hyperpigmented macules or papules appear in the skin due the deposition of yellow-brown pigment in the dermis; these lesions are associated with the topical application of products such as hydroquinone.6 Its effect is potentiated by the action of the corticosteroid, which also inhibits its eczematogenic effect. In most cases, the products do not contain any type of sun screen. Mercury is used in the form of soaps or creams containing mercury iodide (1%–3%), or mercury chloride (6%–8%). Their systemic absorption causes nephrotic syndrome Figure 1 Striae and marked atrophy caused by the long-term use of corticosteroids.